In the fourth quarter of 2022, U-LEAD with Europe organised and held a number of online events that highlighted the latest changes in the process of reforming the healthcare system in Ukraine. In course of the information sessions and consultations held by U-LEAD, representatives of local self-government bodies and the management of healthcare facilities were not only provided with a detailed and professional analysis of the most recent changes in healthcare sector, but were also able to ask U-LEAD experts about planning their activities for 2023. We present the answers to the top three questions.

 

What are the alternative sources of analysis and monitoring of the activities of healthcare facilities?

The powers of the owner of a healthcare facility are quite broad. When planning and implementing these powers, most owners rely on the data provided by the facilities themselves as part of the preparation of local funding programmes and various measures related to health care, the process of reporting or approval of the financial plan. But are these inputs always enough to make balanced decisions? What resources can be used to obtain additional information or verify information provided by a healthcare facility? One of the open sources of verified information is E-DATA presented as dashboards and posted on the website of the National Health Service of Ukraine (hereinafter referred to as the NHSU) here. You can always use this service to:

• check the main indicators of primary and specialised healthcare facilities;
• compare these indicators with indicators of other healthcare facilities;
• review and analyse the dynamics of information on income and expenses, the level of remuneration of employees of healthcare facilites by categories;
• investigate the number of prescriptions issued and redeemed, including those under the Affordable Medicines Programme;
• find out whether medicines and medical goods are purchased and identify % of these purchases in the total costs of a healthcare facility.

For example, indicators for analysis can be the number and details of referrals for consultations, tests, hospitalisations and priority services that are formed in a healthcare facility, and the % of their redemption in the same facility in comparison with the % of redemption in other healthcare facilities. On the one hand, these indicators give a clear understanding of whether the residents of the municipality that receive these referrals have access to those medical services. On the other hand, they help identify priority medical services or consultations that should be organised locally. In turn, if the % of outstanding referrals is higher than the average for other healthcare facilities, this is a reason for further investigation of the causes of this situation by the owner together with the facility itself. It is also necessary to keep track of the indicators of purchases of medicines and medical goods in comparison with the indicators of other healthcare facilities that are similar in terms of the scope of services.

 

What are the approaches to financing “health care” measures from the municipal budget?

On 3 November 2022, amendments to the Budget Code of Ukraine were adopted, excluding sub-paragraphs а, а-1, b, c і d from paragraph 3 of Article 89(1) From now on, Article 89 stipulates that healthcare expenditures made from the budgets of municipalities with centres in villages, towns or cities include:

e) payments for municipal services and energy for municipal healthcare facilities owned by the relevant municipalities to ensure the provision of medical services under the programme of state healthcare guarantees for the population; 

f) local programmes for the development and support of municipal healthcare facilities owned by the relevant municipalities, local programmes for the provision of medical services to the population in excess of the scope provided for by the programme of state healthcare guarantees for the population;

g) local public health programs.

Given the ambiguity of the interpretation of sub-paragraph e “on payments for municipal services” and the standard use of sub-paragraph f, it is sub-paragraph g that raises the most questions and contradictions in terms of the practical aspects of its implementation. When developing budget programmes that are in any way related to health care, the broad scope refers specifically to sub-paragraph f, in contrast to sub-paragraph g, which deals with public health. Wording such as “support and development of health care” is typically used in the names of health care budget programmes, although it is not uncommon to talk about measures that are not directly related to either the development or support of health care. To a greater extent, these measures meet the needs of either the entire population of the municipality or certain groups of the population, e.g. the purchase and provision of personal protective equipment, the purchase of medicines, food and medical supplies for the individual use of residents, additional vaccinations, etc. As a result, these measures fully fall under the general definition of public health programs, such as:

• epidemic response;
• reproductive health;
• protection of motherhood and childhood;
• diagnostics and prevention measures that are not included in primary medical services (additional screenings, oncology studies, etc.);
• vaccinations outside the national schedule;
• measures to ensure the work process for medical workers and other workers involved in the provision of socially significant services, e.g. personal protective equipment;
• analytical, outreach, advocacy activities on improving or researching the health status of the population;
• health schools;
• support groups, psychological rehabilitation.

In general, the field of public health is so comprehensive that it provides very wide opportunities for financing measures aimed at improving the quality and length of life of residents of the municipalities. You can learn more about the development and financing of public health programs in the Operational Manual “Development and Financing of Regional and Local Public Health Programmes”

 

Planning activities and reorganisation of healthcare facilities, which include units of both primary and specialised medical care

Although the primary and specialised health care facilities in the vast majority of municipalities are registered as separate legal entities, there is a number of municipalities that will face separating these units into separate legal entities in 2023. So should they be separated? According to the pre-war plans of the Ministry of Health, the separation of primary and specialised levels of medical care was supposed to be completed by 1 July 2022 but was postponed due to the war and martial law. In turn, Ms. Husak, Head of the NHSU, in an interview dated 26 July 2022, noted that splitting off primary and outpatient specialised units such as outpatient care departments and/or outpatient rehabilitation care departments was not mandatory. However, specialised inpatient medical care and primary care will not be contracted jointly in one legal entity. Therefore, the owners of such institutions should consider separating such units now. 

This leads to an organisational question of whether to split off the primary unit and leave the specialised unit or, vice versa, to split off the specialised unit.

At the moment, the draft Resolution of the Cabinet of Ministers of Ukraine “On Certain Issues of the Organisation of a Capable Network of Healthcare Facilities” (hereinafter the Resolution) is being finalised. It provides, among other things, for the submission of plans for a capable network of healthcare facilities within hospital districts by 1 May 2023, as well as for the creation of development plans for the facilities of this network for the next 3 years. Therefore, further steps in the planning of the activities of municipal healthcare facilities must be made taking into account these requirements or at least based on the criteria for determining the status of healthcare facilities. Pursuant to Clause 6 of the draft Resolution, starting in 2024, the National Health Service is to procure medical services based on the capable network. According to Mr. Yaremenko, Deputy Minister of Health, those hospitals with specialised units that will not be part of the capable network can be developed toward providing expanded primary medical care with a specialised consultative outpatient clinic, day surgery unit.

The final recommended model and minimum scope of specialised services are to be developed in the near future.  Therefore, unless your healthcare facility does not fall under the capable network or has powerful specialised inpatient units, right now is the time to consider the model of providing medical services for your healthcare facility. Then you can make appropriate decisions about the procedure for splitting off the primary or specialised units and about the further reorganisation of the facility based on this model.